Raymond Verhaeghe

Doppler flowmetry in the planning of perforator flaps

Perforator flaps have become the first choice in free flap reconstruction of contour defects or skin and fat replacement in our department. The Deep Inferior Epigastric Perforator (DIEP), the Superior Gluteal Artery Perforator (S-GAP) and the Thoracodorsal Artery Perforator (TAP) flaps are now routinely used. By evaluating the vascular anatomy of these flaps preoperatively, we intend to improve our surgical strategy so that these operative procedures can proceed in a faster and safer way. In this study, the results of the colour Duplex scanning in 50 consecutive DIEP flap patients are reviewed and evaluated for their sensitivity and positive predictive value. Also the preoperative information from unidirectional Doppler flowmetry in 30 S-GAP flaps and 11 TAP flaps is evaluated for its reliability. Due to the variable vascular anatomy of the lower abdominal wall and the dorso-lateral thoracic wall we now prefer using the colour Duplex scanning for planning the DIEP and TAP flaps. The more constant course of the branches of the superior gluteal artery allows us to use the easier and cheaper unidirectional Doppler flowmetry for planning the S-GAP flap.

Prevalence and Causes of Anaemia in a Geriatric Hospitalized Population

Of 732 consecutive patients admitted to an acute geriatric ward, 178 (24%) were found to be anaemic (haemoglobin of 115 g/l or below). An appropriate cause responsible for anaemia was identified in 83%. The anaemia of chronic disorders (ACD) (35%) and iron deficiency anaemia (15%) were the commonest causes. The spectrum of disorders associated with ACD is much broader than the classical category of infectious, inflammatory and malignant disorders. The relatively high prevalence of the myelodysplastic syndrome (5%) is striking and this syndrome as a cause of anaemia in geriatric patients deserves more attention than it has so far received. No obvious cause was found in 17%. The clinical significance of this finding remains unclear.

A comparative trial of a low molecular weight heparin (enoxaparin) versus standard heparin for the prophylaxis of postoperative deep vein thrombosis in general surgery

BACKGROUND Various studies have been performed in general surgery patients comparing low molecular weight heparin (LMWH) with standard heparin (SH) for the prevention of postoperative deep vein thrombosis (DVT), revealing contradicting results. Therefore, we have compared the efficacy and safety of a LMWH for the prevention of DVT after major general surgery. PATIENTS AND METHODS Patients received either 20 mg LMWH (enoxaparin) once daily, or 5,000 IU SH TID, starting preoperatively in a prospective, randomized, double-blind international multicenter trial. DVT was diagnosed using fibrinogen I 125 leg scanning. Major and minor bleeding were assessed clinically. RESULTS A total of 718 patients were randomized to LMWH, and 709 patients to SH. DVT was detected in 58 LMWH-treated patients (8.1%, 95% confidence interval [CI] 6.2% to 10.3%) and in 45 patients allocated to SH (6.3%, 95% CI 4.7% to 8.4%, P > 0.05). Major bleeding complications occurred in 11 LMWH-treated patients (1.5%, 95% CI 0.8% to 2.7%) and in 18 patients to whom standard heparin was administered (2.5%, 95% CI 1.5% to 3.9%, P > 0.05). Four LMWH-treated patients (0.6%) required reoperation for bleeding as compared to 13 patients in the SH group (1.8%, P = 0.03). CONCLUSION This LMWH appeared as effective and safe as SH. In view of its more convenient way of administration, this LMWH might be preferred for thromboprophylaxis.

Catheter-directed lysis of iliofemoral vein thrombosis with use of rt-PA

Abstract The aim of our study was to evaluate the results of catheter-directed thrombolysis and complementary procedures to treat acute iliofemoral deep vein thrombosis (DVT). A total of 24 consecutive patients with acute iliofemoral DVT underwent intrathrombus drip infusion of alteplase (3 mg/h; mean dosage 86 mg, range 45–174 mg), while intravenous heparin (1000 U/h) was continued. Complementary procedures were hydrodynamic thrombectomy in 3 and primary insertion of a Wallstent in 9 patients. Patency of 19 thrombosed veins (79 %) was restored with prompt symptomatic relief. An underlying anatomical anomaly or lesion was present in 13 patients: iliac vein compression syndrome (n = 8), absent (n = 2) or obstructed (n = 1) vena cava or venous stenosis (n = 2). Ten of the abnormalities were unknown before lysis and eight were relieved by stent deployment. Puncture site bleeding was the only complication but led to transfusion in 6 patients (25 %). Symptomatic reocclusion occurred in 4 patients. Catheter thrombolysis of iliofemoral vein thrombosis revealed many anatomical abnormalities which may predispose to thrombosis and are often amenable to stenting.

Thrombolytic Therapy of Peripheral Arterial Occlusion With Recombinant Staphylokinase

BACKGROUND Recombinant staphylokinase (STAR) induces fibrin-specific coronary artery recanalization in patients with evolving myocardial infarction. The present pilot study evaluates its thrombolytic efficacy, safety, fibrin specificity, and immunogenicity in patients with peripheral arterial occlusive disease. METHODS AND RESULTS Thirty patients (37 to 86 years of age) with angiographically documented thromboembolic peripheral arterial occlusion of recent origin (21 +/- 5.5 days, mean +/- SEM) were treated with heparin and intra-arterial STAR given as a 1-mg bolus followed by a 0.5-mg/h infusion in 20 patients or as a 2-mg bolus followed by a 1-mg/h infusion in 10 subsequent patients. With 7.0 +/- 0.7 mg STAR infused over 8.7 +/- 1.0 hours, recanalization was complete in 25 patients, partial in 2, and absent in 3. Two major hemorrhagic complications occurred: one fatal hemorrhagic stroke and one hypovolemic shock caused by bleeding at the angiographic puncture site. Administration of STAR did not induce fibrinogen breakdown or a significant prolongation of template bleeding time. STAR-neutralizing activity and anti-STAR IgG were low at baseline, increased markedly from the second week on, and remained elevated for several months. CONCLUSIONS Intra-arterial administration of STAR restores vessel patency in patients with peripheral arterial occlusion in the absence of fibrinogen degradation.

Femoro-popliteal artery thrombolysis with intra-arterial infusion of recombinant tissue-type plasminogen activator--report of a pilot trial

Recombinant tissue-type plasminogen activator (rt-PA) was infused at a rate of 10 mg/h into 50 thrombosed femoral and popliteal arteries. Patency was restored in 43 but a secondary angioplasty led to 2 reocclusions and in 3 patients early rethrombosis occurred. A favourable clinical result was thus obtained in 38 patients (76%). Thirteen bleeding complications occurred in 10 patients, mainly haematomas at puncture sites. One patient required blood transfusion for gastro-intestinal bleeding from a previously unknown ulcer. The angiographic recanalisation rate in 16 patients who received a slower infusion of rt-PA (5 or 3 mg/h) was 94% and the clinical success rate in this series was 81%. However, the incidence of bleeding complications was not decreased by the slower infusion rate. The data obtained confirm the feasibility of rt-PA thrombolysis in peripheral arterial thrombosis and warrant a comparative study with streptokinase.

Predictive value of nailfold capillaroscopy in the diagnosis of connective tissue diseases

SummaryWe revised the clinical files of 326 patients who underwent nailfold capillaroscopy. These patients could be subdivided into 4 groups : I : patients with clinical suspicion of connective tissue disease, II : patients with isolated Raynauds phenomenon, III : patients with existing connective tissue disease, IV : patients with acrocyanosis, chronic pernio or related disorders. The presence of megacapillaries was noted. The sensitivity of their presence for the various categories of connective tissue disease was as follows : systemic sclerosis (n=11) : 100 %, CREST (n=15) : 73 %, MCTD (n=9) : 56 %, dermatomyositis (n=7) : 86 %. Nineteen patients with megacapillaries had no final diagnosis of connective tissue disease (specificity 93.3 %). The positive predictive value of the presence of megacapillaries for a scleroderma spectrum disorder (SSD) was 63.5 % and the negative predictive value of a normal capillaroscopy 96.7 %. We conclude that nailfold capillaroscopy can be advised to rule out SSDs.

Cobalamin absorption and serum homocysteine and methylmalonic acid in elderly subjects with low serum cobalamin

Abstract: We prospectively studied 41 consecutive elderly patients with serum cobalamin (vitamin B12) levels lower than 125 pmol/l. The protein‐bound cobalamin absorption test (PBAT) was performed in 34 of them and in 27 selected elderly control patients. The lower decision limit was 0.18% and an abnormal test was detected in only 9 (26%) of the 34 patients with low serum cobalamin level. When the PBAT was compared to the Schilling (Dicopac method) test, a concordant result was found in 80 %. Serum methylmalonic acid and/or total homocysteine concentrations were elevated in 75% (26/35) of the patients with low serum cobalamin levels but also in 30% (5/17) of the control patients. Of the 12 and 9 cobalamin‐deficient patients with elevated serum levels of methylmalonic acid and homocysteine, normalization after cobalamin therapy was obtained in 11 and 5 respectively. In conclusion, determination of serum metabolites and their response to cobalamin therapy are a sensitive index of significant cobalamin deficiency and a useful means of distinguishing between cobalamin and folate deficiency. The PBAT offers little advantage over the Schilling test in diagnosing cobalamin malabsorption in elderly patients.

Multicenter pilot study of the efficacy and safety of systemic rt-PA administration in the treatment of deep vein thrombosis of the lower extremities and/or pelvis

Patients with symptoms of deep vein thrombosis for less than 10 days were treated with a standard dose of heparin. In the open label phase of the trial, 11 patients received 100 mg rt-PA on the first day and 50 mg on the subsequent day in an 8 hour infusion. In the double-blind phase, 8 patients were randomized to the same rt-PA regimen, 6 patients to an infusion of 50 mg rt-PA over 8 hours on days 1 and 2, and 7 patients to placebo infusions. The mean change in venographic score in all patients treated with rt-PA plus heparin is -3.8 units compared to -0.6 units in patients treated with heparin alone (p = 0.06). Bleeding complications classified as major were noted in 8/25 patients receiving the combined treatment.

Single intravenous administration of TB-402 for the prophylaxis of venous thromboembolism after total knee replacement: a dose-escalating, randomized, controlled trial

Summary.  Background: TB‐402 is a novel anticoagulant monoclonal antibody with a prolonged antithrombotic effect resulting from its partial factor (F)VIII inhibition and long half‐life. We evaluated the efficacy and safety of a single administration of TB‐402 for the prevention of venous thromboembolism (VTE) after total knee replacement (TKR). Patients and methods: This was a phase II, dose‐escalating, randomized, enoxaparin‐controlled, open‐label study. Patients were post‐operatively assigned to a single dose of TB‐402 (0.3, 0.6 or 1.2 mg kg−1) or enoxaparin 40 mg for at least 10 days (n = 75 per group; 3:1 TB‐402 to enoxaparin). The primary efficacy outcome was total VTE defined as asymptomatic deep vein thrombosis (DVT) detected by bilateral venography and symptomatic VTE by day 7 to 11. The principal safety outcome was the incidence of major bleeding and clinically relevant non‐major bleeding. Results: Total VTE was lower in all TB‐402 groups compared with enoxaparin: 16.7%(95% CI 9.8–26.9), 23.9%(95% CI 15.3–35.3), 24.1%(95% CI 16.0–34.5) and 39.0%(95% CI 28.8–50.1) for TB‐402 0.3, 0.6, 1.2 mg kg−1 and enoxaparin, respectively (P = 0.003 for TB‐402 0.3 mg kg−1 vs. enoxaparin). The incidence of total VTE in the pooled TB‐402 groups was 21.6% (95%CI 16.6–27.5), an absolute risk reduction vs. enoxaparin of 17.4% (95% CI 5.2–29.6). Major or clinically relevant non‐major bleeding was observed in 3/75(4.0%), 4/74(5.4%), 7/87(8.0%) and 3/79(3.8%) patients for TB‐402 0.3, 0.6, 1.2 mg kg−1 and enoxaparin, respectively. Conclusions: TB‐402, as a single post‐operative administration, was associated with a lower rate of VTE in all doses tested, compared with enoxaparin. The incidence of major and clinically relevant non‐major bleeding was similar to enoxaparin 40 mg for TB‐402 0.3 and 0.6 mg kg−1.